doi:10.1093/humrep/deh845
Human Reproduction Vol.20, No.7 pp. 1938–1943, 2005 Advance Access publication March 17, 2005
Psychological distress among women suffering from couple infertility in South Africa: a quantitative assessment S.J.Dyer1,4, N.Abrahams2, N.E.Mokoena1, C.J.Lombard3 and Z.M.van der Spuy1 1
Reproductive Medicine Unit, Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Observatory, 7925 and 2Gender and Health Research Group and 3Biostatistics Unit, Medical Research Council, P.O.Box 19070, Tygerberg 7505, South Africa 4
To whom correspondence should be addressed. E-mail:
[email protected]
BACKGROUND: Infertility in Africa is commonly associated with negative psycho-social consequences. To date, most studies from African countries addressing these consequences have been qualitative in nature. The aim of this study was to assess psychological distress quantitatively among women suffering from couple infertility in an urban community in South Africa. METHODS: The Symptom Checklist-90-R (SCL-90-R), a standardized instrument for the measurement of current psychological symptom status, was administered to 120 women at the time of their first presentation to an infertility clinic in a tertiary referral centre. The control group comprised 120 women presenting to local family planning clinics. In addition, socio-demographic information and data pertaining to the prevalence of abuse was captured through a structured questionnaire designed for the purpose of this study. RESULTS: Women suffering from involuntary childlessness scored significantly higher on all sub-scales and the global indices of distress of the SCL-90-R when compared to controls. In addition, women who reported abuse from their male partners had significantly higher scores on six of the 12 test scales when compared to infertile women in non-abusive relationships. CONCLUSIONS: Involuntary childlessness is associated with high levels of psychological distress. Women in abusive relationships are particularly at risk. This result is in keeping with several qualitative studies from African countries which describe infertility as an overwhelmingly negative and distressing experience. Cognizance needs to be taken of these experiences and effective interventions require medical, psychological and socio-cultural strategies. Key words: abuse/Africa/infertility/psychological distress/quantitative research
Introduction Following a period during which population down-regulation was the dominant focus of national and international health policies in Africa, there has been growing interest in the impact of infertility on the reproductive health of men and women in this region. Prevalence rates of infertility are among the highest in the world and the underlying causes (predominantly infectious in nature) contribute to the high burden of disease in African countries (Cates et al., 1985; Ericksen and Brunette, 1996). On a continent where essentially all societies are markedly pronatalist and where the high demand for fertility is fuelled by social, economic and religious imperatives to reproduce, involuntary childlessness carries profoundly negative psycho-social implications. Contrary to the industrialized world, where much of the initial literature on the psychological sequelae of infertility was based on quantitative studies, reports from the developing world have been mostly qualitative in nature. According to these reports, marital instability, divorce, loss of social status, abuse, poverty and stigmatization all form part of the experience of involuntary childlessness (Gerrits, 1997;
Sundby, 1997; van Balen and Visser, 1997; van Balen and Gerrits, 2001; Walraven et al., 2001; Dyer et al., 2002a). Although men are not immune to the suffering associated with infertility (Dyer et al., 2004), women appear to carry the main burden as they are often blamed for non-conception and are more vulnerable to the negative social and economical consequences. As we were not aware of any previous quantitative study assessing psycho-social distress among infertile women in Africa, we set out to explore whether the distress described in the qualitative studies was measurable in quantitative terms. It was the aim of this study to assess whether women from an urban community in South Africa who were suffering from couple infertility had higher levels of distress when compared to non-infertile controls. Psychological symptom status was measured through a standardized instrument, the Symptom Checklist-90-R (SCL-90-R). It is important to emphasize that rather than contributing to the debate of the advantages and disadvantages of qualitative versus quantitative studies in the assessment of psychological distress
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Psychological distress among women in infertile couples
among infertile patients (Greil, 1997), we wanted to expand our understanding of the reality of infertility among women from our local communities. The SCL-90-R has been utilized in a number of studies from the industrialized world evaluating psychological distress among cohorts of infertile men and women (Berg and Wilson, 1990; Downey and McKinney, 1992; Wischmann et al., 2001). The differences in study methodologies and in the socio-cultural context prevent formal conclusions drawn from comparisons between these studies and ours. We did, however, anticipate that such a comparison would still offer valuable insights into similarities and differences in the experience of infertility among women from developed and developing countries. The SCL-90-R has not been formally validated in South Africa. This lack of validation applies to many other standardized instruments. The complexity of validation and the limited resources in developing countries are prominent barriers in this regard. However, the SCL-90-R has been applied as a research instrument to a wide range of communities all over the world (Derogatis, 1994). Materials and methods This study was conducted among women from the local community of Cape Town, South Africa. Women were recruited at the time of their presentation to a tertiary care infertility clinic (study group) or to local family planning services in the public health sector (control group). Socio-demographic characteristics of this community and the structure of the South African public health system have been previously described (Dyer et al., 2002a). Briefly, the community is made up of three major ethnic groups (black, white and coloured/ mixed ancestry). Xhosa, English and Afrikaans are the three languages most commonly spoken. The public health system is structured into three levels of care and is accessible at relatively low cost to all patients who cannot afford private facilities. Couples requiring infertility management are usually referred to tertiary care facilities. This implies that the women who are recruited from the infertility clinic have not received infertility treatment (although they may have had initial investigations) prior to their participation in this study unless they had accessed private health care. One hundred and twenty women were recruited from the infertility clinic at Groote Schuur Hospital (referred to as study group). Women were interviewed without the presence of their partner and in their preferred language. All interviews were conducted by one multilingual professional nurse trained in qualitative and quantitative data capture. A two-part questionnaire was administered. The first part of the questionnaire was developed for the purpose of this study and captured socio-demographic information as well as quantitative data on a number of topics previously addressed in a qualitative study (Dyer et al., 2002a,b). These topics included women’s health-seeking behaviour, reproductive health knowledge (with regard to infertility), expectations of infertility management and the experience of abuse. In the second part of the questionnaire, psycho-social distress was measured using the Symptom Checklist-90-R (SCL-90-R). The SCL-90-R is a 90-item symptom inventory designed to measure current psychological symptom status. Although the test is intended as a self-report measure, it was administered to all participants in order to facilitate understanding and due to the high rate of functional illiteracy in our community. Each item is rated on a five-point scale
of severity. The test generates nine primary symptom dimensions (somatization, obsessive – compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism) as well as three global indices of distress. These indices are the Global Severity Index (GSI) which reflects both number and intensity of reported symptoms, the Positive Symptom Distress Index (PSDI), a marker of symptom intensity, and the Positive Symptom Total (PST) which measures symptom breadth. Results are expressed in area T scores in which the mean is 50 and the SD is 10. Higher scores are indicative of higher degrees of psychological distress. The test mean and SD are generated through a norm group of ,1000 men and women who represent a stratified random sample of ‘normal, non-patient individuals’ living in the USA. The majority of individuals in this sample were white (85.5%) and married (96%). Information on social class and religion is not available for this norm group (Derogatis, 1994). In order to improve the validity of our study, a local control group was added. This group consisted of 120 women who presented to family planning clinics. Clinics were selected in order to recruit controls from the same local districts in which the infertile subjects reside. Informants were recruited consecutively but dependent on the presence of the research assistant at the clinic and the willingness of the subjects to participate. The SCL-90-R was administered together with a brief questionnaire capturing socio-demographic data. Information on health-seeking behaviour, reproductive health knowledge and abuse was not collected in the control group. The interviews in the control group were conducted by three members of our research group, one of whom was the professional nurse involved in the assessment of the study group. Six questions in the SCL-90-R were considered to be potentially confounding in the context of this study (Table I). Endorsement of the idea that ‘something serious is wrong with your body’ could reflect the context of infertility rather than being suggestive of psychopathology. The five questions on the phobia scale were considered a potential source of bias, as the high prevalence of violence in the communities from which the participants of this study were drawn make these concerns entirely appropriate and valid. Following scoring of the complete SCL-90-R, these six questions were therefore subsequently withdrawn. This rendered the phobia scale invalid and led to an adjustment of the scores for psychoticism and the three global indices of distress. Both the original T scores and the adjusted T scores are presented in the Results section. All interviews were held in the preferred language of the informant and the questionnaires were available in the three main languages of our community. The purpose of the study was explained to all potential participants and written informed consent was obtained. Informants who experienced high levels of distress
Table I. Questions resulting in potentially confounding interpretations Question
SCL-90-R Scale
The idea that something serious is wrong with your body Feeling afraid of open spaces Feeling afraid to go out of your house alone Feeling afraid to travel on buses, subways or trains Having to avoid certain things, places or activities because they frighten you Feeling nervous when you are left alone
Psychoticism Phobia Phobia Phobia Phobia Phobia
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and women who reported abuse (study group only) were counselled immediately after the end of the interview and referred for ongoing counselling to a social worker or to organizations dealing with domestic abuse. The study was approved by the Ethics Committee of the Faculty of Health Sciences, University of Cape Town. Statistical analysis Mean T scores for subjects and local controls were calculated and compared. Student’s t-test was used to determine the significance of differences between the mean T scores and other continuous variables. For categorical variables, the two groups were compared by the x 2-test. For comparison of the original and adjusted T scores within each subject, the paired t-test was used. This comparison was done separately for the study and control groups.
Results Socio-demographic characteristics The socio-demographic characteristics of the study group and the control group are listed in Table II. There was no difference in age between the two cohorts. The different languages and religious denominations were equally represented in both groups. Women in the study cohort had significantly lower levels of education and were less likely to be employed when compared to women in the control group (P , 0.05). Among the study group, 106 women (88.3%) were married either by South African law or through religious and cultural traditions. Women in the control group were not asked about their marital status as there was concern that this question might be interpreted as judgemental by informants using contraception in non-marital relationships. As expected, significantly more women in the study group were childless when compared to the control group. Eighty-three women in the study group (69.2%) had no live children and a further 14 informants (11.6%) were childless in their current relationships. The results pertaining to the evaluation of women’s reproductive health knowledge and treatment-seeking behaviour in
Age (years) Mean Range Live children, n (%) Yes No Home language, n (%) Xhosa Afrikaans English Education, n (%) Junior school High school Tertiary education Religious denomination, n (%) Christian Muslim No denomination NS ¼ not significant.
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Control group (n ¼ 120)
29.2 21–40
28.0 20–40
Original and adjusted T scores The mean T scores and their SD generated by the nine subscales and the three global indices (GSI, PSDI and PST) of the SCL-90-R are summarized in Table III. The mean T scores of both the study and the control group were consistently . 50 (which represents the mean of the test norm group). Women suffering from involuntary childlessness had significantly higher T scores on all sub-scales and the three global indices of distress when compared to women in the local control group. The differences in the mean T scores between the study group and the control group remained once we controlled for educational levels (data not shown). The re-analysis of data after exclusion of the six potentially confounding questions led to a significant lowering of the mean T score of the psychoticism scale for subjects and to a lowering of the PST for both subjects and controls without eliminating the significant difference between subjects and controls on either of the two scales (Table IV). The rescoring did not significantly alter the mean T scores of the GSI and the PSDI (data not shown).
P
Abuse Three women declined to answer one or more of the questions relating to abuse. Of the remaining informants, 17 (14.5%) said that their intimate partners had used physical violence against them and in the majority of cases (n ¼ 15) this had occurred on more than one occasion. In 29 (24.8%) women, the partners had used verbal and/or emotional abuse and 26 women reported such abuse from others, particularly from their in-laws. In total, 52 participants (44.4%) affirmed the experience of abuse and in two-thirds of these women (n ¼ 35) this involved the intimate partner. The results of a subgroup analysis of the SCL-90-R profile comparing infertile women suffering from intimate partner abuse (physical, emotional and verbal abuse) to infertile women who had reported no abuse from their partners is demonstrated in Table V. Women in abusive relationships had significantly higher mean T scores on the scales of
NS
Table III. Mean T scores among study group and control group
Table II. Socio-demographic characteristics of subjects and controls Study group (n ¼ 120)
the study group have been previously published (Dyer et al., 2002b).
SCL-90-R Scales
Study group Control group (n ¼ 120) (n ¼ 120)
P
Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Anger–hostility Phobic anxiety Paranoid ideation Psychoticism Global Severity Index Positive Symptom Distress Index Positive Symptom Total
61.0 ^ 7.6 62.7 ^ 7.4 65.2 ^ 6.9 63.6 ^ 5.6 62.1 ^ 7.9 66.2 ^ 8.2 63.3 ^ 7.4 65.9 ^ 6.2 68.0 ^ 7.1 65.9 ^ 6.0 59.5 ^ 8.3 66.0 ^ 6.3
,0.0001 ,0.0005 ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.005 ,0.0001 ,0.0001 ,0.0001 ,0.05 ,0.0001
,0.0001 37 (30.8) 83 (69.2)
83 (69.2) 37 (30.8) NS
39 (32.5) 27 (22.5) 54 (45.0)
42 (35.0) 22 (18.4) 56 (46.6)
16 (13.5) 93 (78.2) 10 (8.4)
4 (3.3) 68 (56.7) 48 (40.0)
98 (81.6) 17 (14.2) 5 (4.2)
108 (90.0) 10 (8.3) 2 (1.7)
,0.0001
NS
Values are mean T scores ^ SD. Norm group: mean ¼ 50.
54.0 ^ 10.8 58.9 ^ 8.9 59.4 ^ 9.0 57.6 ^ 9.8 54.3 ^ 11.3 56.5 ^ 10.0 59.8 ^ 10.0 59.5 ^ 9.4 61.2 ^ 10.0 59.3 ^ 9.5 56.7 ^ 11.0 58.5 ^ 8.6
Psychological distress among women in infertile couples Table IV. Comparison between original mean T scores and adjusted mean T scores among study group and control group SCL-90-R Scales
Psychoticism Original Adjusted Pb Positive Symptom Total Original Adjusted Pb
Study group (n ¼ 120)
Control group (n ¼ 120)
Pa
68.0 ^ 7.1 66.0 ^ 7.9 ,0.0001
61.2 ^ 10.0 60.6 ^ 10.0 NS
,0.0001 ,0.0001
66.0 ^ 6.3 64.8 ^ 5.8 ,0.001
58.5 ^ 8.6 57.6 ^ 8.4 ,0.001
,0.0001 ,0.0001
Values are mean T scores ^SD. Norm group: mean ¼ 50. NS ¼ not significant. a Between-group difference in T scores. b Within-group difference between original and adjusted T scores.
obsessive –compulsive dimensions, interpersonal sensitivity, depression, anxiety, hostility and on the GSI when compared to women in non-abusive relationships.
Discussion The negative impact of infertility on the reproductive health of men and women in Africa is gradually being recognized. This study contributes to the previous qualitative literature by adding a quantitative measure of the distress experienced by infertile women. Our results demonstrate that women suffering from couple infertility in an urban community in South Africa had significantly higher levels of distress when compared to a cohort of women attending family planning clinics for the purpose of obtaining contraception. Although women in the study cohort had lower levels of education, the difference in psychological distress remained when we controlled for educational levels. There are two possible explanations for the observed discrepancy in the level of education between the two cohorts. Infertility may be more common among women with lower levels of education. Although there are a number of plausible explanations for this, including, among others, high-risk sexual behaviour due to a lack Table V. Mean T scores among infertile women in abusive and non-abusive relationships SCL-90-R Scales
Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Anger–hostility Phobic anxiety Paranoid ideation Psychoticism Global Severity Index Positive Symptom Distress Index Positive Symptom Total Values are mean T scores ^ SD. Norm group: mean ¼ 50. NS ¼ not significant.
Abusive relationships Yes (n ¼ 35)
No (n ¼ 85)
63.1 ^ 8.5 64.9 ^ 7.7 67.2 ^ 7.0 65.6 ^ 5.3 64.8 ^ 7.4 70.1 ^ 5.7 65.0 ^ 6.8 67.2 ^ 5.5 69.2 ^ 7.5 68.0 ^ 6.6 61.4 ^ 8.5 67.3 ^ 7.4
60.2 ^ 7.1 61.8 ^ 7.0 64.4 ^ 6.6 62.7 ^ 5.5 61.0 ^ 7.9 64.6 ^ 8.5 62.5 ^ 7.6 65.3 ^ 6.4 67.5 ^ 6.9 65.0 ^ 5.7 58.7 ^ 8.2 65.4 ^ 5.7
P
NS ,0.05 ,0.05 ,0.01 ,0.05 ,0.001 NS NS NS ,0.05 NS NS
of empowerment and the inability to negotiate safe sex or a lack of understanding of possible reproductive health implications, we do not have good regional or national data with which to substantiate this assumption. The importance of education as a determinant of the use of contraception has, on the other hand, been recognized (Bambra, 1999). Integrated into the study questionnaire was a quantitative assessment of the prevalence of abuse. These questions were based on the results of a previously conducted qualitative study among infertile women from the same community which had alerted the clinicians and researchers to the fact that abuse shaped the experience of involuntary childlessness of several of the informants (Dyer et al., 2002a). In this study a total of 35 women (29.2%) suffering from involuntary childlessness reported verbal and/or physical abuse from their partners. These women showed significant T score elevations on five sub-scales and on the GSI when compared to infertile women in non-abusive relationships. As domestic violence was not the main outcome measure of this study, women in the control group were not subjected to the questions on abuse. The results therefore do not provide information as to whether infertile women are at higher risk of abusive relationships than women not currently suffering from involuntary childlessness but indicate that women who are infertile and subject to domestic abuse are particularly at risk of emotional distress. Given the prevalence of reported abuse in this study, the authors are currently planning a follow-up study aimed at screening women attending various reproductive health clinics for intimate partner abuse. This will help to determine overall prevalence rates of abuse and assess whether women suffering from reproductive failure are at higher risk than women who reproduce successfully. We were unable to identify a study from Africa with which to compare our results on psycho-social distress but related data are available from industrialized world studies. Wischmann et al. (2001) applied the German version of the SCL-90-R to infertile couples presenting to a tertiary care institution. Although women suffering from infertility had significantly higher T scores on seven of the nine sub-scales the differences were small. The highest mean values were found on the anxiety scale (mean T score 52.7) followed by somatization (mean T score 51.9) and depression (mean T score 51.9). The authors concluded that their results favoured a ‘de-pathologization’ of patients whilst recognizing that a subgroup of individuals may be sufficiently stressed to warrant professional psychological help. In the USA, Berg and Wilson (1990) applied the SCL-90R to 104 couples involved with infertility investigations. Women had the highest T score elevations on the interpersonal sensitivity scale followed by depression and psychoticism. Subsequent withdrawal of 14 questions considered to be potentially confounding in the setting of infertility resulted in a mean T score reduction of the GSI from 60 to 58 and a reduction in caseness from 52% of the study cohort to 44% (‘caseness’ refers to the presence of psychiatric disorder and is operationally defined as a GSI score of $ 63 or as any two primary dimension scores of $ 63). The authors emphasized the importance of appropriate instruments for 1941
S.J.Dyer et al.
the measurement of infertility-related distress and of distinguishing between psychiatric morbidity and psychological strain. In another American study, Downey and McKinney (1992) used several questionnaires including the Brief Symptom Inventory, which is an abbreviated form of the SCL-90-R, in the evaluation of 118 infertile women. The authors were unable to demonstrate a difference between subjects and controls on any of the sub-scales. While caution needs to be exercised when comparing our results with the above studies, a few issues justify discussion. We share the concern with Berg and Wilson (1990) that some questions of the SCL-90-R may be potentially confounding. We utilized a similar approach of ‘re-scoring’ but were interested to find that this did not substantially influence our results and did not alter the differences in the mean T scores between subjects and controls. We also agree with the recommendation of a de-pathologization of the psycho-social reactions to infertility and therefore elected not to assess ‘caseness’ in our study. In this context it is important to remain focused on the underlying research questions. The aim of this study was to measure psychological distress as part of the social experience of infertility and not to assess whether infertile women have individual traits indicative of psycho-pathology. The problems associated with shifting psychological distress from forming part of the social construct of infertility into a medical model of psychological morbidity have been previously emphasized by Greil (1997). According to the author this medicalized approach to infertility diverts attention from the social conditions which shape involuntary childlessness and from the opportunities to address these. The most important difference between our study and other publications appears to be a greater magnitude of distress among infertile women in our study when compared with patients from the developed world. This distress seems to be greater both in width (number of scales showing T score elevations) and depth (degree of T score elevations). We submit that this distress reflects the profound negative impact that involuntary childlessness has on the emotional, social, cultural and economic realities of women in our community. Our results are in keeping with several qualitative reports from Africa which indicate that involuntary childlessness is usually a distressing experience and associated with marital instability, divorce, abandonment, stigmatization, ostracism and abuse (Gerrits, 1997; Sundby, 1997; Yebei, 2000; Dyer et al., 2002a). Our study shows that the distress that women suffer is measurable in quantitative terms, that it is significant and that it is arguably greater than that which women experience in the developed world. These findings help to corroborate the construct of involuntary childlessness in the developing world, an experience which is common and which, by the very nature of its psychosocial implications, is anything but benign. There are numerous other studies and a myriad of standardized instruments which have aimed at a quantitative assessment of psycho-social distress among men and women suffering from involuntary childlessness. The results of these 1942
studies have been the subject of a number of reviews (Greil, 1997; Brkovich and Fisher, 1998). Two important conclusions, particularly relevant to this discussion, can be drawn from these reviews. Firstly, most quantitative studies concur that individuals suffering from infertility have higher levels of psycho-social distress than controls. Secondly, most of the standard tests utilized have limitations in the setting of infertility and the ‘ideal test’ has yet to be designed. New instruments aimed at being more suitable and specific for infertility have been piloted but generally speaking still require acceptance and validation on a much wider scale (Glover et al., 1999; Franco et al., 2002). The finding that the mean T scores of women in the control group fell consistently between the mean T scores of the study group and those of the test norm group highlights the importance of the control group in the evaluation of our results. Rather than interpreting absolute elevations of T scores we have focused on the observed differences between our two cohorts. It is possible that the raised T scores in the control group are indicative of higher levels of psychological distress among women from low-resourced communities when compared to people in the industrialized world (norm group). Alternatively, this finding may be due to sociocultural factors independent of psychological distress. Our study population was recruited from a cohort of urban women who presented to an infertility clinic at a tertiary institution. It is possible that women who do not seek medical care and women who live in other regions may have different experiences and levels of distress associated with involuntary childlessness. The fact that the majority of research on infertility has, as in our study, focused on clinicbased samples of men and women who seek treatment has been considered a serious limitation (Berg, 1994). However, King (2003), following an analysis on subfecundity and anxiety in a nationally representative sample of American women, concluded that the seeking of medical assistance had no moderating effect and that the results on psychological distress emanating from research on patients attending infertility clinics could indeed be generalized to all subfecund women. We conclude that infertile women in this study experienced higher levels of distress when compared to women not currently infertile. Cognizance needs to be taken of this finding and interventions have to be formulated. Infertility is not only a physiological or patho-physiological condition in need of bio-medical intervention but also an emotional, social, cultural, religious and economic reality (Greil et al., 1988; Kemmann et al., 1998; Sandelowski, 1999). Effective interventions require an understanding of these realities (Sandelowski, 1999; van Balen and Gerrits, 2001). Our study contributes to this understanding where it is currently most lacking, namely in communities from developing countries. Although bio-medical interventions focusing both on preventative measures as well as effective treatment options aimed at restoring fertility clearly have to form part of the strategy, they have to be underpinned by psychological, social and cultural strategies. Experience from the industrialized world has demonstrated the benefits of ‘patient-centred
Psychological distress among women in infertile couples
care’. This term refers to psycho-social care provided as part of routine clinical practice by all health-care professionals involved in the management of the patient (Boivin et al., 2001). Furthermore some couples will benefit from counselling offered by professionals trained in mental health care. Additional tasks, particularly in the developing world, include addressing stigmatization, patriarchal norms, social and gender inequities, reproductive health knowledge and poverty. These latter tasks clearly exceed the scope of healthcare workers and require involvement of teachers, community workers and leaders, cultural reformers, media role players, politicians and indeed patients themselves (Sandelowski, 1999; van Zandvoort et al., 2001). Hand in hand with these strategies is the need to measure infertility treatment outcome not merely in terms of pregnancy rates but also in terms of psychological and social adjustment (Glover et al., 1999). This reconceptualization of successful treatment has the dual advantage of opening new avenues towards the better management of infertile couples whilst perhaps lifting some of the considerable burden that infertility currently places on the scarce health resources of developing countries. Acknowledgements The authors wish to express their gratitude to all the women who participated in the study. We would like to thank Anne Hoffman and Bridget Mangcu for their assistance in the data collection, Andrew Carlyle for his input into the use of the SCL-90-R and Lulama Kepe who helped with the statistical analysis. The Medical Research Council contributed to the funding of the project.
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Submitted on November 12, 2004; resubmitted on February 9, 2005; accepted on February 14, 2005
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